The Role of the Autonomic Nervous System

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60 The Role of the Autonomic Nervous System

Dawn Bhat and Jacqueline Carleton, Psychotherapies (NIP) in New York City, where she works on United States curriculum development. She is co-authoring a book applying Somatic Experiencing techniques to early developmental (attachment) trauma.

This chapter outlines the theoretical development of the Dawn Bhat, MA, MS, NCC, holds graduate degrees in Gen- autonomic nervous system (ANS) in Body Psychotherapy. eral Psychology from Queens College in New York City and Historically, attention to the ANS in psychotherapy stems in Clinical Mental Health Counseling from Long Island Uni- from the work of Pierre Janet and Wilhelm Reich. Modali- versity in Brookville, New York. She received her bachelor of ties of Body Psychotherapy that have emerged since Reich’s science degree from the University of Florida in Gainesville. time have utilized the ANS as a vehicle for organismic reg- She is a National Certified Counselor (NCC) and is a Yoga Alli- ulation. The ANS operates largely out of consciousness at ance (RYT-500) registered Yoga teacher. Dawn is a research the level of the reptilian brain or brainstem, which controls writer for Somatic Psychotherapy Today and has training in involuntary body processes (i.e., heart rate, respiration, neuropsychology and Somatic Psychology. She has been a digestion, etc.). Some modalities of Body Psychotherapy psychotherapy researcher under the guidance of Jacqueline focus on the body-mind experientially—that is, the inner A. Carleton, PhD, of the USABP since 2010, and currently awareness of the viscera, soma, or bodily states. receives clinical supervision from Dr. Carleton. The self-regulatory functions of the ANS include Jacqueline A. Carleton, PhD, is editor of the International homeostatic regulation of bodily functions, emotional Body Psychotherapy Journal: The Art and Science of Somatic balance, and an enhanced capacity for social engagement. Praxis, and has been in private psychotherapy practice in ANS regulation restores the nervous system to a healthy Manhattan since the 1970s. She attended Smith College and cycle of activation and deactivation through the reciprocal MIT, and holds a PhD from Columbia University. Since the workings of the sympathetic (SNS) and parasympathetic 1980s she has taught both Body Psychotherapy (Core Ener- (PNS) branches. Contemporary neuroscience acknowl- getics) and the principles of Psychodynamic Psychotherapy edges that there are, in addition, two branches of the PNS, internationally. Since the turn of the century, she has utilized which are mediated by the dorsal and ventral branches Somatic Experiencing, a neurologically based treatment for of the vagus nerve, and that the latter gives rise to social trauma. She practices and lectures on Somatic Experienc- engagement (Porges, 2011). The quality of the attachment ing in the United States and in Europe and the Middle East. relationship between an infant and its caregiver contributes She is also on the Executive Committee of the Integrative to the early neural development of the self-regulatory func- Trauma Treatment Program of the National Institute for the tions of the ANS.

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In this chapter, we will explore select modalities of and one’s relationship with others. The notion of the “win- Body Psychotherapy that work with the ANS explicitly dow of affect tolerance” was elaborated some years ago by and implicitly. Finally, we will discuss contemporary efforts Allan Schore (2001, 2003), based on the influence of rela- toward integration within the field of Body Psychotherapy tional perspectives to working at the “edge of the window and among forms of verbal psychotherapy to work holisti- of tolerance” where the therapeutic dyad is “safe, but not cally with the underlying neurology and the whole person, too safe” (Bromberg, 2006, pp. 153–202). physically, mentally, and relationally. Historical Roots of Attention to the ANS The Autonomic Nervous System (ANS) in Body Psychotherapy in Body Psychotherapy The historical roots of working with the ANS in Body Psy- For many Body Psychotherapists, the ANS is intimately chotherapy can be traced back to the French psychologist involved in, if not central to, a client’s process when work- Pierre Janet, who greatly influenced Freud, Jung, Adler, ing from a somatic point of view. To understand the impor- Piaget, and Reich. In a seminal article by David Boadella tance of the ANS in Body Psychotherapy is to become (2011), this legacy of Pierre Janet is treated at length. Janet, familiar with the influential—albeit, historically, under- who lived from 1859 to 1947, was a contemporary of Freud, valued in mainstream psychotherapy and psychoanalysis— and ran Charcot’s experimental laboratory on physiologi- theoretical perspectives originally put forth by Wilhelm cal psychology. Janet claimed that psychoanalysis stemmed Reich and subsequently by others. Reich developed con- from his development of a system that he originally called cepts describing the “vegetative nervous system,” which is “psychological analysis.” Janet published his case studies in commonly known today as the ANS. The concept of self- 1886, the first examples of a cure by catharsis. He was influ- regulation is particularly significant for many modalities enced by F. A. Mesmer and his eighteenth-century ideas on of Body Psychotherapy as are other regulatory functions the psychotherapeutic use of hypnosis. of the ANS, including stress modulation. Janet may in fact be called the grandfather of Somatic Body Psychotherapists today not only work with the Psychology and Body Psychotherapy (Boadella, 2011), as expression of cognitions and emotions in the neuromus- he held the position that the body and mind are inseparable cular system, but also focus directly on ANS processes. such that psychology could not be divided from physiol- Integrating what MacLean (1990) described as the “triune ogy (the body). Boadella (2011) suggests that “Janet was brain” in psychotherapy allows the clinician to work with not just a primary inspiration for psychoanalysis, analyti- the hierarchical functions of the whole underlying neurol- cal psychology and individual psychology, he was the first of ogy (Ogden, Minton, and Pain, 2006). The reptilian, limbic, the new generation of psychological analysts to focus on the and neocortical regions of the human brain are related to centrality of understanding the involvement of the body in sensory-motor, affective, and cognitive processes, respec- psychotherapy” (p. 57). A number of topics Janet investi- tively. As such, there is neuropsychological evidence for gated involved the ANS in general, and respiration and dis- applying a “bottom-up” approach, which essentially targets sociation in particular. Janet identified the diaphragmatic the ANS. block in neurotic patients, which influenced the work of One aim in Body Psychotherapy is to increase the Bleuler, who coined the term “schizophrenia” stemming capacity of the ANS to remain within a “window of tol- from schizo (split) and phren (diaphragm). Contemporary erance” (Ogden, Pain, and Fisher, 2006), restoring a state researchers, such as Bessel van der Kolk and Pat Ogden, of homeostasis and ultimately increased resilience in the writing on post-traumatic stress and dissociation, are vali- physical body, which enhances one’s connection to oneself dating Janet’s early ideas. The Role of the Autonomic Nervous System | 617

Janet’s interest in the body-mind connection was the theoretical basis for Reich’s psychosomatic research evident in his insightful ideas on massage, embryologi- emerged. cal development, muscular consciousness, kinesthetic In the 1930s, Reich looked toward the physiology of sense of self, and the relation between movement and the ANS, chemistry of anxiety, electrophysiology of the intentionality—some of which are foundational in many body fluids, and hydromechanics of plasma movements schools of Body Psychotherapy (Boadella, 2011). In in protozoa to generate a theory of the antithesis of vegeta- describing the principles of psychotherapy, Janet (1924) tive life (Boadella, 1973/1985). Reich was concerned with investigated the functioning of the ANS as an important the contrast between the anxiety syndrome caused by the direction for scientific endeavor. Janet talked about visceral adrenal reaction and the cholinergic effect of pleasurable consciousness (Boadella, 2011) and explored the relation- relaxation. During the 1920s, Ludwig Robert Müller had ship between visceral sensations and emotionality. Janet described the two divisions of the ANS: the sympathetic had a gastrointestinal theory of neurosis (later developed and parasympathetic nervous systems (Neundörfer and by Gerda Boyesen) wherein he saw intimate connections Hilz, 1998). The sympathetic effects were identical to the between the peristaltic functions of the gut and emotional adrenal effects, also associated with anxiety reactions, expressivity (Ibid.). whereas the parasympathetic effects were identical to the Since the early twentieth century, there have been many cholinergic effects or the relaxation response, which we other theorists speculating about the interrelated functions discuss in more detail later in this chapter. of the ANS in physical and mental health. Walter Cannon Reich was primarily concerned with which ANS divi- (1871–1945), an American physician, was a contemporary sion is involuntarily predominant in the organism and the of Wilhelm Reich (1897–1957). What Cannon called the associated voluntary reactions that may or may not occur. ANS, Reich called the vegetative nervous system. While Reich’s clinical observations revealed bodily expressions Cannon, who coined the term “fight-flight,” continued his corresponding to a person’s mental attitude. Repression investigations and built his theories (i.e., the Cannon-Bard or inhibition of aggression, pleasure, and anxiety among theory of emotion), Reich developed approaches to psy- other strong emotions were also associated with body choanalysis that took into consideration the physiology of musculature and tension. For Reich, “character armor” the body. and “muscular armor” became functionally equivalent. Reich was the first analyst “to introduce an exhaustive study of just what bodily mechanisms were involved in the The Evolution of the Work of Wilhelm Reich dynamics of repression, dissociation, and other defenses It is the work of Reich that bridges the historical devel- against feeling” (Boadella, 1973/1985, p. 116). Reich opments of Janet to contemporary modalities of Body emphasized the strong impact of the ANS on respiratory Psychotherapy. For Reich, the rhythm of the body is the function and emotional balance and the role the ANS expansion and contraction leading to genital pleasure or played in the functioning of the whole person, physically, cardiac anxiety, respectively. Reich formulated the orgasm mentally, and relationally. In this, he took Müller’s work as mechanical expansion, bioelectric charge, bioelectric to a psychological and clinical level. discharge, and mechanical relaxation—a basic form of veg- In Reich’s therapeutic work with character defenses, etative (autonomic) functioning. This movement of life was energy in the ANS was released, liberating the patient from echoed in Reich’s observations of the plasmatic movements the effects of repression, enhancing their capacity for self- of the amoeba. The nervous system in animals operates regulation, and giving greater resilience in the nervous sys- in parallel to the expansion or elongation and contraction tem. Vegetotherapy, developed by Reich from about 1934, or rounding up of the pulsation in protozoa. From this, was a set of techniques designed to dissolve the person’s 618 | FUNCTIONAL PERSPECTIVES OF BODY PSYCHOTHERAPY muscular armoring (Boadella, 1973/1985). For Reich, at limbic system, which is part of the midbrain, sometimes the end of therapy, the patient should be able to surren- called the “emotional brain.” The hypothalamus (a part of der to their deepest feelings. A free flow of orgone energy the midbrain) is very much involved in regulating ANS throughout the body defined this state (Blasband, 2005). processes, such as stress, arousal, basic survival needs, For Reich, vegetative self-regulation (a healthy ANS) was including hunger, thirst, and sexual behavior, as well as also a principle of healthy adult functioning throughout aggression, pain perception, and the experience of plea- their life span, optimally commencing in infancy and child- sure. The hypothalamic-pituitary-adrenal (HPA) axis will hood (Carleton, 2008). be discussed in more detail later in this chapter, as it relates to the regulation of the stress response and traumatic stress. The unconscious activity of the ANS is mainly inter- Self-Regulatory Functions of the ANS connected within the right hemisphere of the brain and Because of the complexity and interconnectivity of the the limbic system (Damasio, 2000). In the limbic brain, body’s systems, there are many regulatory functions of the amygdala and hippocampus are necessary for the stor- the ANS, including organismic homeostasis, emotional age and processing of emotional and traumatic memory balance, and social engagement. ANS processes operate to be recorded in the brain’s cortex. The amygdala plays mostly unconsciously, involuntarily, and automatically. a distinct part in fear conditioning (LeDoux, 1998), and Homeostasis is achieved via regulation of blood pres- becomes active when there is a threat, which signals the sure, heart rate, gastrointestinal responses (i.e., peristal- survival system leading to ANS preparation for the fight, sis), contraction of the bladder, focusing of the eyes, the flight, or freeze reaction. The body remembers traumatic immune function, and thermoregulation, to name just a events through emotional sensations and ANS arousal few. The ANS innervates cardiac muscle, smooth intesti- (Rothschild, 2000). When ANS arousal is high, releasing nal muscles, and various endocrine and exocrine glands, stress hormones, the activity of the hippocampus, storing influencing most tissues and organ systems throughout cognitive aspects of memory, is suppressed. the body (McCorry, 2007). By and large, the ANS is The function of the orbitofrontal cortex (OFC) in clearly implicated in many, if not most or all, visceral humans is the control of the ANS (Schore, 1999). The OFC functions. is structurally and functionally linked to the interconnectivity within the right cerebral hemisphere with connections with the hypothalamus, autonomic areas, and the A Basic Overview of the Neural Aspects brainstem. Functions of this fronto-limbic cortex include of the ANS arousal reaction, homeostatic regulation, drive modula- A comprehensive understanding of the nervous system— tion, and suppression of heart rate and anger. In terms of from a neuroscientific point of view—has become a key ANS activity, the OFC is implicated in parasympathetic component in many training programs for Body Psycho- decreases in cardiovascular activity and inhibitory influ- therapists. Before we discuss the techniques developed ences on the sympathetic system. Furthermore, this struc- to target ANS (in)activity, we will provide some general ture is involved in socioemotional behaviors, regulation of background that is essential in effectively identifying and the body and motivational states, adjustment of emotional treating any dysfunctions associated with the ANS. responses, and neurodevelopment of the attachment pro- The ANS is very basic or primitive, coordinated mainly cess. It is important to note, however, that a self-regulatory by the “reptilian brain” (i.e., brainstem, medulla, pons) system consists of many different regions in the brain, involuntarily, and has most interconnections with the right including those beyond the realm of the structures that hemisphere of the brain (Schore, 1999, 2000, 2009) and the regulate the ANS (Young, 2007). The Role of the Autonomic Nervous System | 619

ANS functions are also modulated by neurochemicals axis. The regulation system manages states of arousal, and and neurohormones. The sympathetic nervous system consists of the hypothalamus and regions of neurochemi- is associated with increased blood levels of the catechol- cal mechanisms within the brainstem and basal forebrain. amines (norepinephrine and epinephrine), adrenaline, and Three of the major chemical messenger systems that influ- calcium. The parasympathetic nervous system is associated ence cortical arousal in the brain include: (1) norepineph- with increased blood levels of acetylcholine and potassium rine or noradrenergic, which supports sensory alertness; (Heller, 2010). The synthesis of epinephrine is adrenaline, (2) dopamine, which supports prediction of reward and which is greatly enhanced during stress. Neurohormones motor activity; and (3) serotonin, which supports auto- and neuropeptides such as cortisol and other corticoste- nomic control and emotion. The primary connections roids are also involved in ANS regulation. A goal of many occur within the amygdala, regulating emotional reactivity Body Psychotherapeutic interventions is a return to an easy and memory as well as meaning, along with the prefrontal alternation between the sympathetic and parasympathetic cortex in the executive system, which controls motor and nervous systems. Cycles of intense (aerobic) activity fol- behavioral activity (Lillas and Turnbull, 2009). The main lowed by profound rest may help offset any imbalances in chemical messengers for the remainder of the body are the regulation of the ANS by regulating levels of neurohor- cortisol for the heart and adrenaline for the rest of the body. mones (i.e., cortisol) and neurochemicals (i.e., catechol- However, this is not just a “brain” function. Adrena- amines) and thus alleviating psychosomatic pathology. line, cortisol, and corticosteroids flood throughout the whole body: stimulating the heart rate and contractility of cardiac cells; closing down some of the blood vessels in Sympathetic and Parasympathetic the periphery (skin) and making much more blood avail- Nervous Systems able for any intense muscular activity; as mentioned, the For Body Psychotherapists, familiarity with the distinct and digestive system shuts down, the blood supply is shut off, reciprocal roles of the two branches of the ANS is extremely and all intestinal sphincters are contracted (including the helpful in assessing and treating psychological manifesta- urinary sphincter); the bronchioles of the lungs are inflated tions of ANS dysfunction, frequently seen in mood disor- to achieve greater oxygen exchange; the pupils of the eye ders, including anxiety and depression, and traumatic stress are dilated, so as to allow more light to enter the eye and to disorders (among others). In a healthy organism, the func- enhance distance vision. All the external (skeletal) muscu- tion of the sympathetic nervous system (SNS) is connected lar systems also receive a “tweak” to prime them for almost with fear or arousal and initiates instinctive emergency- instant physical activity: they become tense, ready to “fire.” response activity as well as any conscious effort. In contrast, When the brain perceives a threat, it activates these the function of the parasympathetic nervous system (PNS) physiological and behavioral responses, which could supports processes such as everyday gentle activity, normal result in promoting adaptation or allostasis. However, if digestion, deep relaxation, and sleep. While the “fight-or- stress is sustained or increases over time, the allostatic flight” response is associated almost totally with the SNS, load causes damaging changes to the body that can lead the “freeze” response (also “playing dead” and including to disease and long-term psychological or physiological dissociation) is associated more with the PNS, as a reaction imbalances (McEwen, 2006, 2007). Acute stress facilitates either immediately before or after SNS stimulation. adaptation and survival by activating the necessary neural, cardiovascular, autonomic, immune, and metabolic sys- The Stress Response and Traumatic Stress tem responses. In contrast, chronic stress often (or nearly The stress response activates the SNS or adrenergic half of always) has damaging effects resulting in dysregulation the ANS and the hypothalamic-pituitary-adrenal (HPA) of the same systems. As a result of sometimes massively 620 | FUNCTIONAL PERSPECTIVES OF BODY PSYCHOTHERAPY acute and often chronic stress, there is altered structure Under normal conditions, the PNS regulates various and chemistry in the hippocampus, prefrontal cortex, and everyday, healthy, relatively relaxed responses. Associ- amygdala, which may be relatively easily reversible if the ated with activation of the PNS is the healthy relaxation chronic stress lasts only for weeks. However, prolonged response (relative to the activation response), or essentially stress over months or years may have almost irreversible the “back-to- normal” response. In most circumstances, effects on the brain (McEwen, 2008). the PNS is the “default” mode; the SNS is the “emergency” During traumatic stress, the limbic system acti- defensive response. vates the SNS. When “fight-or- flight” responses are The relaxation response is a state of deep rest (Ben- not instantly possible or appropriate, the limbic system son and Klipper, 1975) that decreases metabolism, heart activates the “freeze” response. This frozen or death- rate, and blood pressure. In addition, levels of nitric oxide like state often occurs in victims of child sexual abuse, increase. When the relaxation response (under the influ- rape, and torture when they are unable to fight back or ence of the PNS) is elicited, the muscular tensions of the escape from physical violence. The nervous system stores body can relax and soften; blood flow is returned to “nor- undischarged energy experienced as a state of being over- mal”; the digestive system starts up again; and the hor- whelmed and frozen in fear. If this is frequent or becomes monal “switch” from adrenaline to acetylcholine takes chronic, the inability to return to equilibrium and balance place. The whole nervous system is restored to a healthy, afterward may become the primary difficulty involved in normal level of functioning, and any of those stress hor- the process of recovery from emotional trauma (Levine, mones that are still present (being unused) can then be 2008; Rothschild, 2000). metabolized (digested). The SNS and PNS seem to manifest in three patterns The Freeze Response and the Relaxation Response of interaction: reciprocal inhibition, mutual antagonism, Levine (2010) provides evidence that the “freeze response” and unilateral activity (Schore, 1999). Discharging high immobilizes an individual in the face of trauma, which ANS arousal and returning to rest and balance have been gives rise to the most debilitating somatic symptoms, such goals in much Body Psychotherapy. In addition, the ANS as numbing, being shut down, dissociation, feelings of branches are coupled with the social engagement and entrapment, and helplessness. During extreme arousal of attachment systems, and so therapy also involves coupling the SNS, the PNS is also activated, slowing down or even and uncoupling the branches of the ANS in social and rela- shutting down body systems: in animals, this can be seen as tional engagement situations. “playing dead.” When people are numb, they are dissociated and not “in” their bodies. Trauma manifests in the body as The Social Nervous System tightened, contracted energy, often locked into the muscles or viscera, which is similar to what ethologists call “tonic Polyvagal theory (Porges, 2011) proposes that the vagus immobility” (Levine and Frederick, 1997). Keleman (1985) nerve has different neurophysiological roles that are related also explored this in his classic book, Emotional Anatomy. to three phylogenetic subsystems in the mammalian auto- Animals in their natural environment, when faced with nomic nervous system: communication, mobilization, and a threat, can rebound far more easily than humans can. immobilization. The vagus nerve is located in the brainstem, Unfortunately, humans are much more vulnerable to being but, in the mammalian brain, there are two vagal systems, overwhelmed and traumatized by the activity of the neo- dorsal and ventral. Porges explains that the more primitive cortex, often giving rise to somatization. As such, the body phylogenetic unmyelinated dorsal vagus is present in all ver- does not release the pent-up energy, which then becomes a tebrates and is associated with mobility (i.e., fight-or-flight) focus of Body Psychotherapeutic techniques. and immobility (i.e., vegetative states, the freeze response, The Role of the Autonomic Nervous System | 621 or playing dead) as a survival function. In the mammalian Early Development of the Social Nervous brain, however, there is a myelinated ventral vagal pathway System: The Neuroscience of Attachment that serves an evolutionary function linked to adaptive social, affective, and communicative behaviors. Bowlby (1969) hypothesized that secure attachment rela- The myelinated ventral vagal complex innervates the tionships are the foundation for the growth of self-reliance, supradiaphragmatic structures (larynx, pharynx, soft pal- the capacity for emotional regulation, and also social ate, esophagus, bronchi, and heart) via the nucleus ambig- competence (Sroufe, 2005). As a regulatory theory and a uus, a neuroanatomical substrate unique to the mammalian motivational system, attachment promotes an interactive brain. It also regulates the striated muscles of the head and regulation of biological synchronicity between organisms face, including emotional expressiveness, eye gaze, listen- (Siegel, 2001; Schore, 2000). Resilience is a strong coping ing, and prosody, which are part of the social engagement adaptation that is highly correlated with secure attach- system. The unmyelinated dorsal vagus innervates the ment (Bowlby, 1990), where there is a physiological sense subdiaphragmatic structures (stomach, intestines, among of security and safety (Siegel, 2001). others) via the dorsal motor nucleus. Based on the evolu- The function of the attachment system is to compel the tionary function of the myelinated ventral vagal complex, infant to seek proximity to a caregiver for protection from, Porges asserts that the complexity of social interactions for instance, harm, starvation, unfavorable temperature is regulated via the visceral state (Ibid.)—and vice versa. changes, distress, and separation (Ibid.). Given that this is a Neural regulation of the heart rate is linked to the highly responsive system to danger, the internal experience detection of fear and safety (Ibid.). When the environment tends to be that of anxiety or fear, which can be elicited is perceived as safe, cardiac output is inhibited, the PNS by any perceived (real or not real) or actual frightening is activated, and the organism perceives internal states as experience. Attachment relationships are essential in the calm, enhancing social engagement. When there is a per- organization of inner experience, as well as in neuronal ceived (real or unreal) environmental threat, cardiac output and brain development, including the stress response of is disinhibited, stimulating the heart via activation of the the HPA axis. Uncoupling the attachment system and the SNS in order to support adaptive survival functions, mobi- defense/arousal system is often the target of modalities of lizing to fight or flee, or immobilizing (i.e., playing dead). Body Psychotherapy that incorporate healing attachment Communication and positive social behavior can occur wounds (Heller and Carleton, in process of publication). (“please and appease”) when the defensive limbic structures The development of a resilient nervous system is cen- are inhibited. Additionally, respiration, an involuntary pro- tral to the attachment relationship, and the attachment cess controlled by the medulla in the brainstem, is closely relationship is based on a resilient nervous system, so connected with cardiac activity, which when taken under impairments in this connection can be, of themselves, conscious control decreases heart rate variability. a source of traumatization (Scaer, 2005). Secure attach- Neuroception, a physiological state operating outside of ments are a protective barrier to stress, whereas insecure conscious awareness, may determine a range of experience attachments perpetuate the stress response (Goldberg, and behavior (Ibid.). It is accessed in some modalities of 2000). Stress regulation in infancy is dependent on the Body Psychotherapy to enhance awareness and discharge quality of attachment relationships (Beebe and Lach- ANS energy. Polyvagal theory thus helps to shed light into mann, 2002; Tronick, 2007; Gold, 2011). Recent research some of the neurophysiological mechanisms involved in by Tharner and colleagues (2013) revealed that higher Somatic Psychotherapies, such as Somatic Experiencing, levels of maternal depression were associated with lower developed by Peter Levine, which accesses the “felt sense” resting respiratory sinus arrhythmia (RSA). If a caregiver and tracks visceral sensations to achieve ANS regulation. is not present, not attuned, or depressed, the infant may 622 | FUNCTIONAL PERSPECTIVES OF BODY PSYCHOTHERAPY not be given an opportunity to interactively regulate imately six months. Higher levels of oxytocin were present stress, thus impeding the development of a resilient ner- in couples who stay together longer than six months and can vous system and the capacity for self-regulation. be enhanced through interactive reciprocity, which includes Autonomic control is the outgrowth of the experience- affectional touch (Schneiderman et al., 2012). In a similar dependent maturation of the OFC (Schore, 2001). The OFC vein, maternal touch has been shown to improve antonomic represents internal working models, a cognitive set that functioning in premature infants (Jean and Stack, 2012), allows for affect regulation and stress adaptation (Schore, supporting the early work of Eva Reich, who explored 1999). The PNS in the frontal lobes develops more slowly gentle, nurturing infant touch in preventing armoring and than the SNS. Schore (1999) posits that, “under optimal expanding energy while also promoting attachment and conditions the two branches, initially uncoupled, become regulation. Touch in psychotherapy is a powerful tech- progressively coupled during development, especially in nique (Young, 2007) used in many modalities of Body Psy- the postnatally maturing OFC” (p. 324). In suboptimal chotherapy (e.g., Rubenfeld Synergy Method, Biodynamic conditions, there is inhibition and repression of uncon- Psychotherapy, and Bioenergetics) and has been utilized to scious affect. The ability to shift in and out of ANS states, or repair attachment disruptions (Carleton, 2010). alternating between SNS dominance and PNS dominance, Irrespective of disrupted attachment style, there is a is known as the stress-state recovery mechanism and may capacity in every human being to repair the self via cor- result in either underregulation or overregulation distur- rective emotional experiences and to promote secure bances. Optimally, affect regulation, mentalization, and a attachment, creating healthy adult relationships. A Body sense of self (Fonagy et al., 2004) develop. Psychotherapist can try to lower the person’s arousal, meet A self-regulated child engages in the process of self- some of the unmet needs on an attachment level, and then determination of the body and its functions. Reich noticed move, through time, to integrate all this into the pres- that children who were not allowed to “self-regulate” stored ent. As attachment wounds are healed, the authentic self the memories of repression within their nervous and mus- engages more in the present (Heller, 2010) and the body cular systems and, as a result, were more prone to mental also realigns its autonomic regulatory systems. and emotional symptoms such as anxiety, neurosis, and depression as well as improper immune function and dis- The Role of the ANS in Awareness of eases of the body (Neill, 1960). Orgonomists believe a parent Body and of Self must be relatively self-regulated themselves to raise a self- regulated child (Carleton, 1991). We might translate that Body Psychotherapists pay careful attention to how a client in current conceptualizations as “securely attached.” “Early perceives visceral information and feelings from their body, life events, especially the mother-infant bond, are crucial for which is an implicit, subjective process. The sense of the maturation of the experience-dependent cortical, sub-cortical, physiological condition of the body has been called intero- and autonomic nervous systems” (Carleton and Padolsky, ception (Craig, 2003). The British physiologist Charles 2012). In attachment trauma, the SNS is constantly in a state Sherrington (1906) described proprioception (awareness of over-arousal. The body needs to complete interrupted of one’s own body) as an integration of exteroception (sen- physiological sequences related to threat in order to allow sory awareness from outside the body) and interoception the SNS and PNS to alternate appropriately. (awareness of organs and processes from inside the body). The coupling between a healthy stress response and The conscious awareness of emotions and feelings (Dama- healthy attachment relationships is supported by oxytocin sio, 2000) is located in the dorsal posterior insula, which (Pierrehumbert et al., 2010). Oxytocin is also associated perceives the body, including pain, temperature, touch, with stability in new romantic relationships up until approx- muscular and visceral sensations, vasomotor activity, hun- The Role of the Autonomic Nervous System | 623 ger, and thirst (Craig, 2003). The right anterior insula may Self-Regulation in Body Psychotherapy also provide the basis for the subjective image of the material self as a feeling entity (Ibid.). Since the 1970s, pioneering thinkers in Body Psycho- This interoceptive awareness is intrinsically involved in therapy (Levine, 1979a and 1979b; Liss, 1979) have writ- meditation and mindfulness practices, which are explicitly ten about the regulation of ANS functions in Energy & integrated in some Body Psychotherapies (e.g., Hakomi) Character, the only publication for many years dedicated (Heller, 2010). Mindfulness, a concept often associated to disseminating the breadth of knowledge within the field with Buddhism, is practiced to enhance happiness and to of Body Psychotherapy. They (Levine, 1979a, 1979b; Liss, gain insight into the true nature of one’s existence. Mind- 1979) have pointed out that there is an energetic relation fulness has been defined as the nonjudgmental awareness between the SNS and PNS that influences organismic of experience in the present moment (Kabat-Zinn, 2003). regulation. The practice of mindfulness encompasses focusing one’s Cognitive, affective, and sensory-motor processes can entire attention on the experience of thoughts and emo- also impact the ANS indirectly via neural projections from tions, as well as bodily sensations, with curiosity, open- the neocortex. For example, movement may be inten- ness, and acceptance. Improving inner awareness facilitates tional, one can decide to “calm down,” and respiration can self-regulation, an inner sense of security, a reduction in be taken under conscious control. According to Heller anxiety, and resiliency in the autonomic nervous system (2012), this explains why individuals can influence these (Bhat and Carleton, 2013). systems by indirect modalities, such as breathing exercises, Mindfulness practices activate the prefrontal cortex, relaxation, Yoga exercises, and mindfulness. Basically, and a mature prefrontal cortex (PFC) allows one to focus, “the vegetative system [ANS] is a part of the mechanisms of concentrate, attend, and imagine (Graham, 2013). The PFC organismic regulation. It is consequently used in all of the regulates the autonomic nervous system, the flow of emo- interactions between the dimensions of the psyche and the tions, and the surge of feelings; calms the activated amyg- body” (Ibid., p. 198). dala; allows attunement to other people, empathy for self When tension and stress are chronic and prolonged, and others; and allows for insight and awareness. Implicit, the “relaxation” stage does not fully engage and the organ- automatic, and reflexive patterns are brought into aware- ism stays somewhat stressed: if this persists, then this ness and when one notices this, one can choose to change “somewhat-stressed” position becomes the person’s “usual” them intelligently and sensitively. resting state, but this is a state of relative hypertension. If Finally, it has been postulated that mindfulness cre- there is further stress that does not get fully resolved, then ates a secure attachment with the self (Siegel, 2007). This another “resting” state is created, but at a higher level of felt sense of security for the self has been compromised stress and bodily tension. We can thus build up layers and in many clients seeking Body Psychotherapy. In addition layers of emotional distress and physiological stress and to mindfulness training, many Body Psychotherapists tension. apply some aspect of the Focusing techniques developed Prolonged relaxation, or combinations of relaxation by Eugene Gendlin (1998). Focusing takes mindfulness a and physical therapy (like massage), are then needed to little further to involve the body and a new kind of expe- restore the organism to a “healthy” level of balance and rience, the felt sense. The felt sense is a freshly forming functioning. Awareness of this is key to any Body Psycho- whole-body sense of one’s life situation, which has great therapeutic approach, and many approaches combine both transformative power (Cornell, 2013). emotional work, psychological and cognitive aspects, with actual physical techniques to assist a proper rebalancing of 624 | FUNCTIONAL PERSPECTIVES OF BODY PSYCHOTHERAPY the ANS by helping to regulate visceral functions. Notable forming into warmth and wellness through the process here is the work of Gerda Boyesen and her development of of emotional release. That is, when there is no rebound Biodynamic Psychotherapy (Boyesen and Boyesen, 1980). between the SNS and PNS, repression, contraction, and Emotional balance arises from the self-regulatory func- tensions may become chronic. When an individual is tions of the ANS. According to Totton (2003), “affect” (in chronically unhappy, a whole array of somatic symptoms psychology, affect is the experience of feeling and emo- has the opportunity to emerge. When these systems do not tion and the resulting presentation of the person) “is more alternate effectively or discharge energy simultaneously, the and more deeply understood as a complex neurological organism is dysregulated and in an abnormal state. Breath- phenomenon—one which, just as it philosophically marries ing is irregular. In addition, depression can be understood mind and body, neurologically marries the CNS and ANS, as energy depletion due to the lack of rebound between the voluntary and involuntary aspects of our embodiment” these two systems. (p. 34). Incomplete and/or simultaneous discharge within both branches of the ANS may generate disturbances in emo- Organismic Regulation and Emotional Balance tional well-being. Symptoms associated with incomplete Physical and mental health are both associated with emo- sympathetic discharge are aggression, palpitations, and tional balance and the efficiency of energy expenditure. The nervousness. Symptoms associated with incomplete para- reciprocal interaction of the SNS and PNS branches of the sympathetic discharge are depression, fatigue, gastrointesti- ANS is an energetic one. The SNS spends energy through nal troubles, nausea, vomiting, diarrhea, and constipation. action, and the PNS regains energy through rest. These two During simultaneous activation resulting in the freeze systems work basically alternately. Spending energy is also response or a vegetative state, blood pressure decreases, known as “sympathetic discharge,” and regaining energy is muscles become flaccid, numbness and dissociation occur, “parasympathetic discharge” (Liss, 1979). affect may be flat, and memory storage, processing, and Positive and negative emotions are associated with both retrieval are impaired, manifesting in some level of amnesia SNS and PNS dominance (Ibid.). When the body is reac- (Levine, 2009). tive, sympathetic dominance generates the positive emo- The body speaks through contraction, immobility, or tions of pleasure or active joy. When the body is receptive, hyperarousal triggered by trauma. The therapist assesses parasympathetic dominance generates the positive sense the functioning of the client’s ANS and, based on these of melting pleasure (joy), as in making love. On the other evaluations, makes inferences about the client’s brain func- hand, negative emotion or distress caused by sympathetic tions. Through reading the body, the therapist systemati- dominance may present as rage, anger, frustration, irrita- cally identifies the regions of chronic muscular holding bility, etc. Distress caused by parasympathetic dominance and constricted breathing patterns. Therapeutic objec- may present as hurt, fear, sadness, shame, or guilt. After the tives involve softening or opening each armored segment “completion” of the active emotions (sympathetic state), and breaking the feedback loop, which activates the fight/ rebound occurs and the person feels relaxed, warm, and flight/freeze response from thelocus coeruleus (contain- receptive (parasympathetic state). ing norepinephrine neurons) in the brainstem. As a result, Emotional discharge or expression is often not suf- the relaxation response occurs, sensations start to flow ficient (is incomplete) without the presence of another through the body, and numbness or hyperarousal is cor- person to help one rebound from the more vulnerable rected. In addition, body-oriented techniques are utilized feelings of hurt, fear, and sadness and restore regulation to assist the patient to develop a conscious awareness of and resilience. Unhealthy emotions and their tensions emotional trauma so that it can be therapeutically resolved stay in the body, manifesting as “knots” rather than trans- (Young, 2008). The Role of the Autonomic Nervous System | 625

Modalities of Body Psychotherapy Biodynamic Psychotherapy Working with the ANS Developed by Gerda Boyesen, Biodynamic Psychology and The focus on the ANS in Body Psychotherapy can be attrib- Psychotherapy works “with” the client’s life force, or their uted mostly to the pioneering work of Wilhelm Reich and vital energy, rather than “against” the tensions. The Boye- his followers in pre–World War II Norway, and then later in sen approach also offers a unique contribution to Body other parts of Europe, and in America, post–World War II. Psychotherapy: the theory of “psycho-peristalsis” (Boyesen In this next section, we will highlight some of the therapies and Boyesen, 1980). The concept of gastrointestinal (GI) that were developed from this impetus of Reichian therapy. functioning is especially relevant to mental health practi- There are many more modalities of Body Psychotherapy tioners, as many psychiatric disorders in the Diagnostic and that warrant attention in this section; however, to review Statistical Manual of Mental Disorders are associated with any more would be too exhaustive for the scope of this GI complaints (American Psychiatric Association, 2013). chapter. Biodynamic Psychotherapy operates under assumptions similar to those of Reichian therapy as to the function of the orgasm, but also theory particularly emphasizing the BBBioenergetic Analysis role of the ANS in self-regulation. In healthy regulation, Alexander Lowen and John Pierrakos studied directly both branches of the ANS alternate in a complementary with Reich in America, and together they developed fashion to mediate vasomotor and emotional cycles form- the method of Bioenergetic Analysis, describing bioen- ing the patterns of emotional regulation. ergy as a “force,” the energy dynamics in life processes. In Biodynamic Psychotherapy, any physical release of Bioenergetic techniques include breathing, grounding, the ANS—such as yawning, crying, sweating, shivering, expressive movement, exercises, physical contact, sound, relaxing, etc.—also opens up the possibility for associated and touch, through which emotional and psychological peristaltic movements and borborygmi (tummy rum- blocks become expressed and feelings become more felt blings). Boyesen focused on stimulating the parasympa- within the psychodynamic processes (Lowen, 1976). thetic side of the ANS, particularly through her Biodynamic These techniques focused on “breaking down” some Massage. Psycho-peristalsis is the body’s way to digest of the chronic (sympathetic) tensions, but they did not both emotions and stress hormones. When a vasomotoric explicitly incorporate much stimulation of the (parasym- cycle is not completed (i.e., emotions go unexpressed), the pathetic) aspects in relation to the ANS, except for the emotional “charge” is stored in the body as some form of grounding exercises. physical tension and stress. In Biodynamic Psychotherapy, Modern Bioenergetic theorists (Baum, 2011) note that massage is used along with listening to these borborygmi people strive to experience pleasure and aliveness, not just through a stethoscope. The therapist’s “goal” here is to help to release unpleasant tension. Although there is a paucity of to increase the peristaltic sounds, a process that is indica- literature within the field of Bioenergetic theory on work- tive of the release of uncompleted emotional or vasomo- ing with the ANS explicitly, Bioenergetic therapists’ work toric cycles and a “switchover” from sympathetic (holding) with the ANS is implied, such that “aliveness, the embrace to parasympathetic (release). As such, the primary regula- of energy and charge, and the possibility for the connec- tor of bioenergy is thus found in the intestinal organs, and tion to goodness and benevolence, to love and joy, are at the “emotional” digestive system is the body’s own method the center of our work” (Ibid., p. 8). of daily emotional self-regulation. 626 | FUNCTIONAL PERSPECTIVES OF BODY PSYCHOTHERAPY

Recent research (King, 2011) described borborygmi as effect on the person’s somatic energy, on their emotional a body phenomenon and an embodied reaction. When the balance, and in moving their life forward. therapist explicitly addresses borborygmi, by engaging in verbal commentary, the therapeutic process can deepen Rubenfeld Synergy Method and fresh new material may emerge. Early prenatal experiences may be a somatic entrance to deepen the psycho- The Rubenfeld Synergy Method (RSM) combines gentle therapeutic process, as the fetus constantly listens to the touch and talk therapy. After several sessions of the Alex- mother’s borborygmi. Somatic Psychotherapists are aware ander Technique, Ilana Rubenfeld developed her method of the connection between the mind and the gut, so this after she found herself bursting into tears and was flooded study complements Boyesen’s development of Biodynamic with memories that the Alexander Technique, a primarily Psychotherapy and the discovery that peristaltic sounds are somatic method, did not address (Medina and Montgom- part of the self-healing or self-regulating ability of the body. ery, 2012). So, Rubenfeld sought help from a psychoanalyst to deal with the psychological manifestations of the touch therapy. She then synthesized Gestalt Psychotherapy with Biosynthesis Feldenkrais’s work (Rubenfeld, 2000). Rubenfeld believed In the 1970s and 1980s, David Boadella developed a form that, “emotions and feelings arise hand in hand within the of Body Psychotherapy that he called Biosynthesis, which brain and the body. To grasp them, the patient needs touch he defines as an integration of life that is founded on the and talk” (Medina and Montgomery, 2012, p. 74). understandings derived principally from Reich and also During the application of passive therapeutic touch (the from embryology (Boadella, 1987). It is understood that “Listening Hand”), the patient will feel something happen- the basic patterns of expansion and contraction occur in ing in his or her body and is invited to express the experi- all life-forms. One somatic technique in Biosynthesis that ence verbally. This combination of talk and touch during addresses hyperactivity of the sympathetic nervous system, the session aids the practitioner in attending to the patient whereby chronic states of tension persist, is “centering,” to more wholly (Medina and Montgomery, 2012). Integra- establish a functional rhythmic flow of metabolic energy tion of touch and talk therapy into the present moment and homeostasis in the ANS: the internal organs are all during a session can release tension from the body, bring endodermic in origin. Another is “grounding,” which the person to a state of relaxation, and achieve body-mind establishes a relationship with the (mesodermic) volun- connection—goals aligned with those of Somatic Psycho- tary and involuntary movement systems within the body to therapists working with the ANS. address hypertonicity and hypotonicity. The former is associated with chronic activation of the sympathetic nervous Sensorimotor Psychotherapy system, and the latter is associated with negative symptom- atology connected to the parasympathetic nervous system, Ogden and colleagues (Ogden, Minton, and Pain, 2006; such as lethargy and depression. “Facing,” the third somatic Fisher and Ogden, 2009) describe Sensorimotor Psy- technique, addresses imbalances in the ectodermic struc- chotherapy, another form of Body Psychotherapy that tures (brain and skin), manifesting as oversensitivity and encourages the client to understand how movement, undersensitivity to sensory information by directly work- physical response, and posture are related to accompanying ing with eye contact and integration of language in per- thoughts, beliefs, and emotions, especially in connection to ception. Finally, the integration of centering, grounding, trauma. The client becomes aware of how beliefs can affect and facing—associated with the affects of the endoderm, posture and how posture affects thoughts and emotions. mesoderm, and ectoderm, respectively—has a profound Therapists utilize a “bottom-up” process to address more The Role of the Autonomic Nervous System | 627 primitive, automatic, and involuntary functions underlying sometimes even contraindicated. In Somatic Experienc- the client’s traumatic and post-traumatic responses. ing, narrative is used to track autonomic activation, not In Sensorimotor Psychotherapy, as the therapist assists to search for memories. The therapist must work within the client to track his or her sensory-motor experience, a range of resilience by never pushing through the client’s physiological signs of arousal are reduced or increased, but resistance or promoting catharsis. only at levels that are manageable for the client. Clients Somatic Experiencing techniques and principles explic- observe and report interactions between their emotions itly focus on regulation of the ANS. Pendulation facilitates and physical sensations. Top-down cortically mediated an individual to pendulate effectively between states of functions are utilized as clients observe and report the resource and states of highly charged traumatic energy. interplay of bodily sensations, emotions, and thoughts; Pendulation is utilized to shift bodily awareness from while bottom-up processing of trauma-related sensa- regions of relative ease to those of discomfort and distress, tions, arousal, movement, and sensory-motor responses based on innate rhythms of contraction and expansion of within the client’s window of tolerance facilitates adaptive the ANS, alternating between the SNS and PNS. “Resourc- responses (Ogden, Pain, and Fisher, 2006). ing” is used to develop the ability to tolerate what has been impossible to tolerate. Because the present moment is a resource in Somatic Experiencing, just tracking what goes Somatic Experiencing on in the session may in itself lead to more organization Peter Levine (2010) described the treatment goal of Body and greater coherence. Additional resources are identified Psychotherapy as the activation of the innate capacity and alluded to throughout the treatment. The patient’s for self-regulation. According to him, survivors of emo- resources are reparative and aid in the process of titration. tional trauma need to develop tolerance for all sensations, “Titration” involves introducing traumatic material in small whether pleasant or unpleasant (Levine, 2008). Survivors amounts to prevent retraumatization. It keeps the nervous are encouraged to complete their fight-or-flight responses, system activation within the “window of tolerance.” The in the form of minute movements of the arms or legs, to energy locked into the system by trauma is most effectively engage their self-protective reflexes. The brain registers this released gradually. In this way, unpleasant, distressing sen- new experience, and equilibrium is restored in the nervous sations are followed by comfortable, relaxing sensations system; natural resilience is activated, which heals trauma. that work on the levels of both the SNS and PNS. Empirical studies have shown the efficacy of Somatic Expe- It is important for the therapist to be able to recog- riencing in working with trauma (Leitch, 2007; Parker, nize signs of discharge without inhibiting them in either Doctor, and Selvam, 2008; Leitch, Vanslyke, and Allen, oneself or the client. Some signs of discharge of traumatic 2009; Whitehouse and Heller, 2008). activation may be sweating, crying, shaking and trembling, In the Somatic Experiencing paradigm, there are prin- coughing, etc. Somatic Experiencing practitioners strive ciples designed to aid in attending to the experience of to bring awareness to as many elements of experience as visceral sensations and to discharge residual ANS energy possible. As such, the discharge of trauma activation can (Bhat, Carleton, and Hippel, 2013). Somatic Experienc- occur through awareness of any of the following five ele- ing techniques (Levine, 2009) may be utilized to promote ments: sensation, image, behavior, affects, and meaning. healthy stress responses affecting the biological defense The therapist allows significant amounts of time for the system and the attachment system and subsequently affec- nervous system to reorganize itself after each intervention. tive and cognitive functioning. When the body is highly The goal of the therapist is to find where in the sequence dysregulated, stuck in chronic patterns of activation, tra- completion of the traumatic response was thwarted, and ditional verbal therapy alone may often be unsuccessful or to guide the client through to relaxation and a sense of 628 | FUNCTIONAL PERSPECTIVES OF BODY PSYCHOTHERAPY triumph and relief. If the therapist is more embodied, the it is very useful for the tears to flow. Crying may be an client’s wish to heal draws from the therapist’s state (Napier, unspoken voice, indicative of dispelling trapped energy 2011). Similar to many therapies, in Somatic Experiencing from the body (Levine, 2010). the client responds more to how the therapist is, not what By thinking culturally, Somatic Psychotherapists can the therapist says: assuming that wisdom rests in the client, connect deeply with a client, especially when working to the therapist is letting the experience of the client guide the move a client through a painful, distressing event. After a therapy session. client cries, the body can relax. However, depending on The role of the breath in ANS regulation has long been what culture a client may identify with, there may be dif- a cornerstone of Body Psychotherapy. Levine asserts that ferences in working with releasing the ANS. Though tears neocortical interventions may restore the regulatory func- are an innate human phenomenon, not everyone cries the tions of the nervous system; however, rigidly controlled same (van Hemert et al., 2011), as cultural differences in breathing may prevent deeper homeostasis. Levine stresses freedom of expression explain differences in crying rather that, when you feel like you need to take that deep breath, than actual distress or suffering. feel the sensation that wants you to take the deep breath instead. As such, the culminating experience of work- Integration and Research ing with the breath is coherence or a full-bodied breath Utilizing an integration of techniques designed to balance resulting in shifts in consciousness (Somatic Experiencing the ANS from different modalities of Body Psychotherapy Trauma Institute, 2012). promotes deep healing and transformation on somatic, affective, cognitive, intrapersonal, and interpersonal levels. Integration in Body Psychotherapy Within the field of psychotherapy, researchers and practitioners are moving beyond a single-school approach and Based on the experience of many Body Psychotherapists, toward assimilation of techniques and theories into more utilizing somatic techniques that target ANS processes of an integrative approach (Stricker and Gold, 2002). This penetrates to the physiological roots of suffering and helps kind of integration is frequently happening in the field of the client to reattain a healthy balance that extends to the Body Psychotherapy. emotional and psychological as well. Trauma resolution, The convergence of phenomenological experience with using recent somatic techniques, leads to greater resilience empirical verification is a developing interest within the and increased life satisfaction—freeing the person from field of Body Psychotherapy (Bhat, Carleton, and Hippel, the “emotionally heavy obstructions within our nervous 2013). There are ongoing collaborative efforts of the Euro- system that hinder our potential for a healthy, thriving, and pean Association for Body Psychotherapy and the United generative development” (Carleton, 2010). States Association for Body Psychotherapy that include the development of research initiatives to provide greater Cultural Considerations in Discharging evidence for some of these theories and clinical techniques ANS Energy of the various institutes, most of which originated outside Crying is a primitive reflex and is a discharge of sympa- of academia. thetic activation. As such, allowing the impulse to cry may serve to restore fight responses. If the client has a fixed References pattern of crying, the therapist might ask them to simply stay with the impulse to cry in order to help them learn to American Psychiatric Association. (2013). Diagnostic and contain and integrate the emotion (Levine and Frederick, statistical manual of mental disorders (5th ed.) (DSM- 1997). Other clients might be emotionally shut down, and V). Washington, DC: Author. The Role of the Autonomic Nervous System | 629

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